197606651-6-6-2023-28-AS-LMOA-CSJUJV-20230606153809

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197606651
Report Date: 06/06/2023
Date Signed: 06/06/2023 03:38:14 PM

Document Has Been Signed on 06/06/2023 03:38 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	LAKEWOOD GARDENS		FACILITY NUMBER:	197606651
ADMINISTRATOR:	MARIE JEENE R DE CASTRO		FACILITY TYPE:	740
ADDRESS:	12055 S. LAKEWOOD BLVD.		TELEPHONE:	(562) 869-4038
CITY:	DOWNEY	STATE: CA	ZIP CODE:	90242
CAPACITY:	150	CENSUS: 72	DATE:	06/06/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:01 AM
MET WITH:	Jeenne De Castro - Administrator		TIME COMPLETED:	03:52 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Luis Mora conducted an unannounced annual visit at the facility using the CARE Tool. LPA Mora met with Jeenne De Castro (Administrator) and explained the purpose of today's visit. The facility is licensed to serve 150 non-ambulatory residents 60 years and above. The facility has a dementia special program, delayed egress system and hospice waiver granted for 27 residents. A tour of the single-story facility included: reception area, all common areas/rooms, 1 common restroom, 1 visitor restroom, kitchen, 7 random resident rooms, 7 random resident private bathrooms, 2 outside patios, medication room, and storage room. LPA and Jeenne De Castro toured the facility and the following was observed: the 2 outside patios are clean and there are shaded seating areas for the residents. Passageways and exits are free of obstruction. Facility has a delayed egress system in all exit doors and was operating at the time of the visit. The water temperature was tested in the 7 private residents’ bathrooms, 1 common restroom, and 1 visitor restroom and measured between at 109.2 and 119.2 degrees F, which is within the required 105 - 120 degrees F. The bathrooms are clean and have the required grab bars in the shower and near the toilet for non-ambulatory residents. Showers also have non-skid materials. Resident bedrooms have the required furniture such as bed frames, dressers, lamps and chairs. Bedrooms also have enough closet space. Resident beds have the required linen and the linen is in good condition. There are extra clean linen and towels in the resident bedroom closets. Facility has a sprinkler fire alarm system throughout the facility. Each resident bedroom has a battery operated smoke detector and carbon monoxide detector and were operating during the visit. There are battery operated carbon monoxide detectors in the all common area/rooms and were operating during the visit. There are multiple fire extinguishers throughout the facility and were last inspected on 05/17/23. Kitchen appliances are clean and were operating at the time of the visit. Sharps are kept in the kitchen and are inaccessible to the residents. Cleaning supplies and toxins are kept in a locked storage room. Sufficient supply of 2 days perishable & 7 days non-perishable foods was observed in the kitchen. First Aid kit was fully stocked with current manual and it is kept in the medication room. Residents medication are centrally stored in the medication room. Residents and staff files are centrally stored in the administrator’s office. The signal system was tested and is operational. Fire inspection was last conducted on 03/08/2023. Fire and Disaster drill was last conducted on 05/01/2023. (Continued to LIC 809-C)

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Luis Mora	TELEPHONE: 323-981-3964
LICENSING EVALUATOR SIGNATURE:	DATE: 06/06/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: LAKEWOOD GARDENS	FACILITY NUMBER: 197606651
	VISIT DATE: 06/06/2023

NARRATIVE

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Resident personal rights, Local Ombudsman, and Let Us Know posters were observed on the hallway wall. LPA reviewed files for 7 residents and 6 staff. LPA observed administrator certificate for Jeenne De Castro – 6044782740 with an expiration date of 06/10/2023. Administrator submitted her administrator certificate renewal application with all required documents on 03/29/23 and application is still pending. A copy of a valid liability insurance was provided to the LPA.

During this visit, the LPA completed the following CARE Tool domains: Infection Control Practices, Operational Requirements, Physical Plant/Environmental Safety, Staffing, Personnel Records/Staff Training, Resident Records/Incident Reports, Resident Rights/Information, Food Service, and Disaster Preparedness. LPA will return at a future date to conduct interviews with staff and residents, and complete the following CARE Tool domains: Planned Activities, Incidental Medical and Dental, and Residents with Special Health Needs.

Per California Code of Regulations, Title 22, and California Health and Safety Code, there were no deficiencies observed during today's visit. Exit interview held and a copy of the report were provided to the Administrator.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Luis Mora	TELEPHONE: 323-981-3964
LICENSING EVALUATOR SIGNATURE:	DATE: 06/06/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2023

LIC809 (FAS) - (06/04)

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